Douglas A. Girod

Risk factors for pulmonary complications in the postoperative head and neck surgery patient

Pulmonary complications are a primary source of increased cost and morbidity in surgically treated head and neck cancer patients. This study investigates potential risk factors related to postoperative pulmonary complications (pneumonia, adult respiratory distress syndrome (ARDS), and prolonged mechanical ventilation) in head and neck cancer patients.

Radiation-Induced Malignancy of the Head and Neck:

OBJECTIVE: Our goal was to evaluate our experience with radiation-induced malignancy (RIM), compare that experience to the literature, and review treatment modalities. STUDY DESIGN AND SETTING: The setting is the University of Kansas Medical Center. A retrospective review was performed to identify patients with RIM. Patients were included if they met the criteria for RIM as delineated in the literature. RESULTS: Thirteen patients met the criteria for RIM. The mean latency period was 22 years. Sarcomas were the most common type of RIM and the paranasal sinuses were the most common location. Surgical resection was our treatment of choice. CONCLUSIONS: Our patient series differs from previous reports in that sarcomas were the predominating RIM and the paranasal sinuses were the most common location. We noted a shorter latency period than has been previously published. Surgical excision is the treatment of choice. EBM rating: C.

Osteocutaneous radial forearm free flaps. The necessity of internal fixation of the donor-site defect to prevent pathological fracture.

Background: Osteocutaneous radial forearm free flaps have fallen from favor due to pathological fractures of the radius. The purposes of this study were to propose a means to decrease the rate of pathological fracture by prophylactic fixation of the donor-site defect and to evaluate this technique biomechanically. Methods: Two groups of ten matched pairs of fresh-frozen cadaveric radii were harvested. In Group 1, an eight-centimeter length of radius comprising 50 percent of the cross-sectional area of the bone was removed to simulate an osteocutaneous radial forearm donor-site defect. This defect was created in one member of each pair, with the other bone in the pair left intact. In Group 2, both members of the ten matched pairs of radii had identical defects created as previously described. However, one radius in each pair had a twelve-hole, 3.5-millimeter dynamic compression plate placed across the segmental defect. In each group, five matched pairs were tested to failure in torsion and five matched pairs were tested to failure in four-point bending. Results: In Group 1, the intact radius was a mean of 5.7 times stronger in torsion and 4.2 times stronger in four-point bending than the radius with the segmental resection. In Group 2, the radius that was ostectomized and fixed with a plate was a mean of 4.0 times stronger in torsion and 2.7 times stronger in four-point bending than the ostectomized radius. Conclusions: Removal of an eight-centimeter segment from the radius dramatically decreased both torsion and bending strength. Application of a plate over the defect in the radius significantly restored the strength of the radius (p = 0.01). Clinical Relevance: The segmental defect created in the radius when an osteocutaneous radial forearm free flap is harvested weakens the donor bone an unacceptable amount, resulting in a high risk of pathological fracture. We believe that prophylactic internal fixation of the donor-site defect with a plate restores strength to such a level that pathological fracture may be prevented, thus increasing the utility of the osteocutaneous radial forearm free flap.

Round window administration of gentamicin: a new method for the study of ototoxicity of cochlear hair cells

Damage to inner ear sensory hair cells after systemic administration of ototoxic drugs has been documented in humans and animals. Birds have the ability to regenerate new hair cells to replace those damaged by drugs or noise. Unfortunately, the systemic administration of gentamicin damages both ears in a variable fashion with potentially confounding systemic drug effects. We developed a method of direct application of gentamicin to one cochlea of hatchling chickens, allowing the other ear to serve as a within-animal control. We tested variables including the vehicle for application, location of application, dosage, and duration of gentamicin exposure. After 5 or 28 days survival, the percent length damage to the cochlea and regeneration of hair cells was evaluated using scanning electron microscopy. Controls consisted of the opposite unexposed cochlea and additional animals which received saline instead of gentamicin. Excellent damage was achieved using gentamicin-soaked Gelfoam pledgets applied to the round window membrane. The percent length damage could be varied from 15 to 100% by changing the dosage of gentamicin, with exposures as short as 30 min. No damage was observed in control animals. Regeneration of hair cells was observed in both the base and apex by 28 days survival.

Identifying incident oral and pharyngeal cancer cases using Medicare claims.

BackgroundBaseline and trend data for oral and pharyngeal cancer incidence is limited. A new algorithm was derived using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to create an algorithm to identify incident cases of oral and pharyngeal cancer using Medicare claims.MethodsUsing a split-sample approach, Medicare claims’ procedure and diagnosis codes were used to generate a new algorithm to identify oral and pharyngeal cancer cases and validate its operating characteristics.ResultsThe algorithm had high sensitivity (95%) and specificity (97%), which varied little by age group, sex, and race and ethnicity.ConclusionExamples of the utility of this algorithm and its operating characteristics include using it to derive baseline and trend estimates of oral and pharyngeal cancer incidence. Such measures could be used to provide incidence estimates where they are lacking or to serve as comparator estimates for tumor registries.

The role of the osteocutaneous radial forearm free flap in the treatment of mandibular osteoradionecrosis.

OBJECTIVE: To evaluate the role of the osteocutaneous radial forearm free flap (OCRFFF) in the treatment of mandibular osteoradionecrosis (ORN). STUDY DESIGN AND SETTING: Retrospective case review of patients who underwent OCRFFF oromandibular reconstruction after resection of nonviable tissue at an academic tertiary care center because of ORN. Patients with reconstructions other than OCRFFF were excluded from this study. RESULTS: Nine patients underwent a composite oromandibular resection for ORN with a reconstruction using an OCRFFF between April 1998 and February 2003. All patients had failed previous less aggressive surgical and medical management of the ORN. Mean follow-up was 36 months (range, 14-67 months). There were no flap failures or significant immediate postoperative or long-term complications observed. All patients had successful restoration of mandibular integrity and continuity, with 100% success rate of stabilization of ORN. All patients were able to tolerate PO diet, with only one third having to supplement their diet with gastrostomy feedings, compared with 89% gastrostomy dependence preoperatively. CONCLUSIONS: Primary or adjuvant radiotherapy for head and neck malignancies can result in ORN of the mandible. This difficult problem often requires surgical intervention. In our experience, the OCRFFF can be successfully used for oromandibular reconstruction, even in the setting of the heavily radiated tissue with excellent postoperative outcomes. SIGNIFICANCE: This is the first study that demonstrates the efficacy of the OCRFFF as a treatment of mandibular ORN.

Acellular dermis compared to skin grafts in oral cavity reconstruction

To compare the efficacy of acellular dermal matrix (ADM) and split thickness skin grafts (STSG) in oral cavity reconstruction.

Use of the 2.0-mm Locking Reconstruction Plate in Primary Oromandibular Reconstruction after Composite Resection

OBJECTIVE: To review our experience with 2.0-mm locking reconstruction plate (LRP) system for patients requiring oromandibular reconstruction. STUDY DESIGN: Retrospective case review of 43 consecutive patients who underwent mandibular composite resection with immediate reconstruction. SETTING: Tertiary care center. RESULTS: Forty-three patients underwent oromandibular reconstruction with the 2.0-mm mandibular LRP system and free flaps containing vascularized bone. Mean follow-up was 11 months. There were no intraoperative difficulties utilizing this system. Two (5%) patients had partial fasciocutaneous flap loss resulting in plate exposure. There were no instances of plate fracture or complications requiring plate removal to date. CONCLUSION: 2.0-mm LRP mandibular system is reliable even in the setting of previous or adjuvant radiation therapy. Its technical ease of application, contouring malleability, and very low profile have proven to be advantageous in oromandibular reconstruction. SIGNIFICANCE: No previous descriptions of use of the 2.0-mm LRP in combination with osteocutaneous free flaps for mandibular reconstruction are found in the literature. EBM rating: C.

Central nervous system plasticity during hair cell loss and regeneration

Following cochlear ablation, auditory neurons in the central nervous system (CNS) undergo alterations in morphology and function, including neuronal cell death. The trigger for these CNS changes is the abrupt cessation of afferent input via eighth nerve fiber activity. Gentamicin can cause ototoxic damage to cochlear hair cells responsible for high frequency hearing, which seems likely to cause a frequency-specific loss of input into the CNS. In birds, these hair cells can regenerate, presumably restoring input into the CNS. This review summarizes current knowledge of how CNS auditory neurons respond to this transient, frequency-specific loss of cochlear function. A single systemic injection of a high dose of gentamicin results in the complete loss of high frequency hair cells by 5 days, followed by the regeneration of new hair cells. Both hair cell-specific functional measures and estimates of CNS afferent activity suggest that newly regenerated hair cells restore afferent input to brainstem auditory neurons. Frequency-specific neuronal cell death and shrinkage occur following gentamicin damage to hair cells, with an unexpected recovery of neuronal cell number at longer survival times. A newly-developed method for topical, unilateral gentamicin application will allow future studies to compare neuronal changes within a given animal.

Outcomes of the Osteocutaneous Radial Forearm Free Flap for Mandibular Reconstruction

IMPORTANCE Limited donor and recipient site complications support the osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction as a useful option for single-stage mandibular reconstruction. OBJECTIVE To examine and report long-term outcomes and complications at the donor and recipient sites for patients undergoing the OCRFFF for mandibular reconstruction. DESIGN Retrospective review. SETTING Academic, tertiary care medical center. PATIENTS The study population comprised 167 consecutive patients who underwent single-staged mandibular reconstruction with an OCRFFF. MEAN OUTCOME MEASURES Rates of complications at the donor and recipient sites. RESULTS The mean patient age was 61 years (range, 20-93 years). Men compromised 68% of the population. Follow-up interval ranged from 2 to 99 months (mean, 25.9 months). The median length of bone harvested was 7 cm (range, 2.5-12.0 cm). Prophylactic plating was completed for each of the radii at the time of harvest. Donor site complications included radial fracture (1 patient [0.5%]), tendon exposure (47 patients [28%]), and donor hand weakness or numbness (13 patients [9%]). Recipient site complications included mandible hardware exposure (29 patients [17%]), mandible nonunion or malunion (4 patients [2%]), and mandible bone or hardware fracture (4 patients [2%]). Using regression analysis, we found that patients were 1.3 times more likely to have plate exposure for every increase of 1 cm of bone harvest length; this was statistically significant (P = .04). CONCLUSIONS AND RELEVANCE This is the largest single study reporting outcomes and complications for patients undergoing OCRFFF for mandibular reconstruction. Prophylactic plating of the donor radius has nearly eliminated the risk of pathologic radial bone fractures. Limited long-term donor and recipient site complications support the use of this flap for single-stage mandibular reconstruction.